Coverage and Access Changes During Medicaid Unwinding

Key Points Question How did insurance coverage and access to care change among low-income households during the Medicaid unwinding process? Findings In this survey study of US low-income households in 4 Southern states in late 2023, 1 in 8 respondents who had Medicaid reported exiting the program roughly 6 months into the unwinding process, with wide state-level variation in coverage loss. Roughly half of those in the sample who lost Medicaid coverage became uninsured. Meaning The results of this study suggest that state and federal policymakers should pursue policies to mitigate adverse outcomes associated with coverage disruptions during and after Medicaid unwinding.


Introduction
3][4][5][6] In late 2022, Congress passed legislation to end the continuous coverage provision; states resumed eligibility redeterminations in early and mid 2023. 7itial projections suggested that this unwinding of continuous coverage would be followed by 15 to 18 million people losing Medicaid benefits. 8However, by early May 2024, the number of people disenrolled from Medicaid exceeded 21 million. 9Most people who have lost Medicaid thus far (70%) were disenrolled due to administrative or procedural reasons, which include the inability or failure to complete paperwork, rather than confirmed loss of eligibility. 9Policies governing this process and disenrollment rates vary considerably by state. 10,11ile administrative data show the number of enrollees losing Medicaid coverage, they do not track enrollees' coverage transitions nor offer insights into how unwinding is associated with enrollees' access to and affordability of medical care. 12High-quality federal surveys will eventually illuminate some of these dynamics, but these data are subject to considerable time lag. 13 provide timely insights into how Medicaid unwinding affects individuals in the US experiencing low income, we conducted a multimodal survey of adults in 4 states during late 2023.
Respondents were US citizens who reported 2022 incomes less than 138% of the federal poverty line (FPL).The survey assessed changes in insurance coverage and access to care.The 4 states in our sample (Arkansas, Kentucky, Louisiana, and Texas) took varied approaches to unwinding.Arkansas conducted redeterminations on an accelerated 6-month timeline; most states took a year. 146][17] Texas conducted redeterminations over a full year, prioritizing cases thought likely to be ineligible, and aiming to conduct most redeterminations during the first 6 months. 18The federal government allowed states to waive certain requirements to implement strategies to improve the retention of eligible enrollees during unwinding; the number of these optional strategies pursued by states in the sample ranged from 4 (Texas) to 14 (Kentucky). 49Additional details on the unwinding policies of states are available in Supplement 1.

Outcomes
Among respondents (and, when applicable, their children) who had Medicaid coverage at any point since March 2020, the primary outcome was self-reported disenrollment from Medicaid (that is, not reporting Medicaid coverage at the time of the interview).Secondary outcomes were current health care coverage among Medicaid disenrollees (Medicare, employer-sponsored insurance, marketplace insurance, other coverage, or uninsured), whether respondents had experienced a gap in coverage (lasting 1 month or longer) during the previous year, and several measures of access to and affordability of care: delayed care during the previous year due to cost, delayed medications during the previous year due to cost, reporting care was less affordable than a year ago, and whether a person had a checkup during the previous year.Exact survey question wording is available in the eMethods in Supplement 1.

Statistical Analysis
First, we summarized characteristics of the full sample and subset of respondents who reported having Medicaid coverage since March 2020.We then estimated rates for the primary outcome, loss of Medicaid, stratifying by state for adult respondents.To assess the validity of our results, we compared state-level Medicaid losses reported in the sample with Medicaid disenrollment rates in administrative data that were concurrent with the timing of our survey and estimated the correlation coefficient for those estimates.We then evaluated insurance at the time of the survey among adult respondents reporting Medicaid disenrollment and whether respondents had a gap in coverage during the previous year.
Using multivariate logistic regression, we separately examined factors associated with Medicaid loss among adults and children (for children, we excluded Kentucky from this model, since it did not disenroll any children in 2023).The covariates were state of residence; demographic characteristics, including race and ethnicity, age, education, employment, income, and parental status (for adults); receipt of Supplemental Security Income (SSI), receipt of Supplemental Nutritional Assistance Program (SNAP) benefits (which may be associated with an increased likelihood that a person had been in contact with state agencies or that the state had adequate income information for their eligibility redetermination); and whether the respondent had moved since March 2020 (which may have been associated with a reduced likelihood that a person received renewal paperwork). 23,24 then used a multivariate logistic regression (adjusting for the previously described covariates) to compare access and affordability measures among respondents who exited Medicaid vs those who remained enrolled in the program.All analyses were survey weighted using statespecific benchmarks derived from federal data for the demographic variables listed in the previously described models; each state was weighted in proportion to its share of the sample (ie, more populous states were not weighted more heavily).Weights also adjusted for modality and nonresponse.Statistical analyses were conducted using Stata, version 17 (StataCorp); significance was determined at the 5% level.Among adults who lost Medicaid coverage (n = 168), just fewer than half (80 [47.8%]) were uninsured at the time of the interview (Figure 2), while 52.2% had other coverage.Among disenrollees, 27% (n = 45) reported having insurance through an employer, 13% (n = 22) Medicare, 9.7% (n = 16) Marketplace coverage, and 2.6% other insurance.

Disenrollment From Medicaid and Subsequent Insurance Coverage
Roughly half of those who transitioned to employer or marketplace coverage reported coverage gaps during the prior year.Overall, and including those who became uninsured, only 49 respondents (29.3%) who lost Medicaid transitioned to new coverage without a gap.Among respondents who had Medicaid coverage at the time of the interview, 195 (15.5%) reported a coverage gap during the prior year, potentially reflecting churn in and out of the program.

Factors Associated With Medicaid Loss
Table 2 shows factors associated with disenrollment from Medicaid between March 2020 and fall 2023.Disenrollment was significantly higher among individuals in Arkansas than in Louisiana and Kentucky, although this difference only remained significant in Kentucky vs Arkansas after multivariate adjustment.Disenrollment was significantly higher among younger adults, rural individuals, those who were employed, and White adults (compared with non-Hispanic Black adults), although this last difference was significant only in the unadjusted analysis.Individuals receiving SNAP benefits were significantly less likely to disenroll.Moving and having an income greater than 100% of the FPL during the prior year were significant risk factors for disenrollment, while SSI was associated with lower disenrollment, but all 3 were only significant in unadjusted models.Among children (eTable 2 in Supplement 1), Arkansas had significantly higher disenrollment rates than the other states (Kentucky was excluded from this analysis, since it had 0% disenrollment by state decision in 2023), while being enrolled in SNAP was highly protective against disenrollment.
Characteristics among adults of being uninsured at time of interview after exiting Medicaid were generally similar as those for Medicaid disenrollment (regardless of coverage at the time of the interview) in unadjusted analyses, except there were no significant differences by race and ethnicity or income, and women were significantly more likely to become uninsured than men (eTable 3 in Supplement 1).In adjusted analyses, coefficients associated with state of residence, age, employment, and SSI receipt remained significant.

Access to Care
Figure 3   b Race and ethnicity were self-reported; "Other" included those who identify as American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific Islander, or who selected the Other response in the survey.

Discussion
In this survey of low-income households in 4 Southern states in late 2023, we find that roughly 6 months into the unwinding process, 1 in 8 Medicaid beneficiaries reported exiting the program, nearly half of these adults became uninsured, and those leaving Medicaid experienced more disruptions in medical care than those who remained enrolled.Disenrollment was highest in Arkansas, which started redeterminations earlier than the other states and conducted unwinding on an accelerated 6-month timeline.Texas had the next highest disenrollment rate, likely reflecting the fact that it was the only nonexpansion state in our sample, meaning a much smaller share of nonelderly adults in the state qualify for the program; Texas also frontloaded redeterminations for likely ineligible individuals.The lowest disenrollment rates were in Kentucky and Louisiana, which are expansion states that spread their renewals over the full year and used outside data sources to limit the burden on beneficiaries to demonstrate ongoing eligibility. 25,26This general pattern resembled findings from a recent analysis of administrative data for all 50 states, which found a significant association between disenrollment rates and policies, including Medicaid expansion, alternative data sources for eligibility assessment, and redetermination timing. 11ildren in the sample were less than half as likely to lose Medicaid than adults.This may partially reflect state policy choices: Kentucky suspended redeterminations for enrollees 19 years or younger for 12 months. 17In addition, the income inclusion criteria for the survey, which was less than 138% of the FPL, did not capture many children enrolled in Medicaid or CHIP who may be more likely to have lost coverage than children in lower-income households.Nonetheless, because children represent nearly half of all enrollees in Medicaid and CHIP, these results suggest that millions of children are losing coverage nationally. 27 found that 48% of respondents who reported leaving Medicaid said they were uninsured at the time of the interview.While the remainder moved into new sources of coverage, slightly less than half of those who gained private insurance experienced a coverage gap.1][32][33] While the unwinding process is a key area of focus in 2024, broader issues of continuity of coverage in Medicaid preceded the continuous coverage policy and will persist after the unwinding period ends. 34[37][38] Figure Given the low-income nature of the survey sample, it is likely that many uninsured respondents either remained eligible for Medicaid or would qualify for substantial subsidies to purchase insurance through the Affordable Care Act marketplaces. 39However, fewer than 1 in 10 respondents who had lost Medicaid coverage had enrolled in a marketplace plan.[42][43][44] We identified several significant individual-level factors that were associated with Medicaid disenrollment.Younger adults, those who are working and those with higher incomes during the previous year were more likely to lose coverage (although the latter finding was no longer significant after adjustment); these factors may all reflect greater income mobility and help explain why more than a quarter of disenrollees had moved to employer coverage after

Limitations
Our study had several limitations.First, our response rate was much lower than high-quality federal surveys.However, the response rate was similar to other rapid-turnaround surveys (including the US Census Bureau's Household Pulse Survey), and previous research has validated our survey approach in terms of trends in producing similar trends in state coverage rates as the American Community Survey. 19This year's survey included a partial shift to ABS, and our module on children's coverage is new and should be considered exploratory.Our survey-reported state-level rates of Medicaid disenrollment were highly correlated with concurrent estimates from state administrative data, potentially offering reassurance for our overall approach.
Our sample was limited to residents of 4 Southern states who reported household incomes less than 138% of the FPL in 2022, which may limit generalizability. 11State approaches to unwinding varied considerably; thus, experiences may have been different in other states.Additionally, many individuals with higher incomes would have been affected by the Medicaid continuous coverage provision and unwinding; about half of children and nonelderly adults who had Medicaid in 2021 had household incomes greater than 138% of the FPL. 48Because our survey was limited to US citizens, our results also may not generalize to noncitizen permanent residents who qualify for Medicaid in those 4 states.
As with all surveys, there is potential for reporting errors.Some respondents may have been confused about their Medicaid or SSI status or misreported other characteristics or program participation.We conducted the survey in 2023 but asked about 2022 household income to establish eligibility for the survey, following previous versions of our survey, and also capture respondents whose income may have changed over time (potentially affecting Medicaid eligibility during unwinding).However, because of this, we were unable to determine directly whether respondents remained eligible for Medicaid when surveyed or would qualify for other assistance, such as marketplace subsidies.Finally, our analyses were cross-sectional and cannot establish causality.

Conclusions
The findings of this survey study offer early evidence that approximately half of people with low incomes exiting Medicaid during unwinding have become uninsured, while the other half has largely switched to private coverage.State policy choices have been associated with significant differences in rates of coverage loss, which is consistent with the variation in our study's state-level results.
Medicaid loss was associated with greater barriers to accessing medical care.State and federal policymakers should pursue policies to mitigate adverse outcomes associated with coverage disruptions during the unwinding process and in future efforts to improve continuity of care for beneficiaries in Medicaid.

Overall, 12 .
5% (n = 179) of adults who had Medicaid at some point since March 2020 were no longer enrolled by fall 2023, ranging from 7.0% (n = 19) in Kentucky to 16.2% (n = 82) in Arkansas (Figure 1), with Louisiana (23 [8.2%]) and Texas (54 [14.9%]) falling in between.Fewer dependent children (42 [5.4%] overall) lost Medicaid coverage.The state-level estimates of adult coverage loss were strongly correlated with administrative records of coverage loss in late 2023 (ρ = 0.92); additional details are available in the eAppendix in Supplement 1.

Table 1 .
Characteristics of the Study Sample a Abbreviations: FPL, federal poverty line; NA, not applicable; SNAP, Supplemental Nutrition Assistance Program; SSI, supplemental security income.aDataarefrom a multimodal (telephone + internet)bThe "Other" category for the race and ethnicity variable included those who identify as Asian, American Indian or Alaskan Native, Native Hawaiian or other Pacific Islander, or who selected the other response in the survey.Respondents are not broken out due to small sample size.Race and ethnicity were self-reported.
shows several measures of affordability and access to care, comparing adults who remained enrolled in Medicaid with those who disenrolled from Medicaid.For all 4 measures, adults who disenrolled had significantly worse access and/or affordability, which included more cost-related delays in care (50.8% vs 26.5%), more delays or skipped doses of medications due to cost (44.8%vs 27.1%), reporting that care was less affordable than during the year before (46.5% vs 22.3%), and less likely to have had a checkup during the prior year (57.0% of those disenrolled had no checkup vs 33.6% of people who had Medicaid at time of the interview).Results were generally similar for those who became uninsured vs those with new, non-Medicaid coverage (eFigure 2 in Supplement 1).

Table 2 .
Factors Associated With Adult Disenrollment From Medicaid Since March 2020 a a Table reports results from a logistic regression examining characteristics associated with Medicaid loss among adult respondents; predicted probabilities were estimated using Stata (StataCorp).
3. Affordability and Access to Care Among Adult Medicaid Enrollees vs Disenrollees 45dicaid.Disenrollment was higher among rural adults and (in unadjusted analyses) among those who recently moved, which may indicate the difficulties states have reaching such enrollees to help them navigate the redetermination process.Disenrollment rates were higher for White than Black individuals (with Hispanic individuals falling in between) in unadjusted analyses.Other preliminary research on unwinding has found mixed results, with at least 1 study finding lower disenrollment among White beneficiaries; these results may vary based on the states and data sources being examined and require additional future research to assess effects on disparities.45Individuals in SNAP were less likely to lose coverage, which may reflect the use of eligibility information from other programs by states to streamline redetermination, as well as greater engagement and awareness of state policies among those participating in multiple programs.SSI 46,47cipation was also highly protective, although this is expected, given that SSI in these states automatically confers Medicaid coverage; the fact that there was any reported disenrollment from Medicaid among those reporting SSI may reflect respondent confusion over their SSI or Medicaid status, which is consistent with recent studies on coverage awareness during the COVID-19 pandemic.46,47